Dcumentatin Requirements fr Teaching Physicians (Permissin t reuse granted by HGS Administratrs.) In a teaching hspitals, physician services prvided t patients are reimbursed by Medicare Part B, and physician services furnished fr the general benefit f patients (e.g., supervisin and teaching f residents) are cnsidered hspital services and are reimbursed by Medicare Part A. Practices vary widely amng and within teaching hspitals with respect t the degree f physician invlvement in the care f patients. In sme cases, teaching physicians persnally direct residents in furnishing patient care services. In thers, residents assume a greater degree f respnsibility fr the care patients receive, and teaching physicians exercise nly general cntrl ver the residents' activities. A resident is an individual wh participates in an apprved graduate medical educatin (GME) prgram r a physician wh is nt in an apprved GME prgram but wh is authrized t practice nly in a hspital setting. An apprved graduate medical educatin (GME) prgram is a residency prgram apprved by the Accreditatin Cuncil fr Graduate Medical Educatin f the American Medical Assciatin, by the Cmmittee n Hspitals f the Bureau f Prfessinal Educatin f the American Ostepathic Assciatin, by the Cuncil n Dental Educatin f the American Dental Assciatin, r by the Cuncil n Pdiatric Medicine Educatin f the American Pdiatric Medical Assciatin. The term resident includes interns and fellws enrlled in GME prgrams that are recgnized as apprved fr purpses f direct GME payments made by the Medicare administrative cntractr. (Interns are nw called first-year residents.) Receiving a staff r faculty appintment, r participating in a fellwship, des nt by itself alter the status f a resident. Additinally, this status remains unaffected regardless f whether a hspital includes the physician in its full-time equivalency cunt f residents. The mst imprtant cnsideratin in determining if the services f a teaching physician are eligible fr Medicare Part B reimbursement is the presence f the teaching physician during the key prtin f any service r prcedure fr which payment is sught. This physical presence requirement identifies situatins when the teaching physician is sufficiently invlved in the service, and at the same time, it prvides a standard that can be readily dcumented and verified. Payment fr teaching physician services prvided in teaching settings will be made using the physician fee schedule nly if ne f the fllwing cnditins is met: Services are persnally furnished by a physician wh is nt a resident. A teaching physician was physically present during the critical r key prtins f the service that a resident perfrms. A teaching physician prvides care under the cnditins utlined in the Exceptin fr E/M Services Furnished in Certain Primary Care Centers (belw).
A t eaching setting is any prvider, hspital-based prvider, r nnprvider setting in which Medicare payment fr the services f residents is made by the Medicare administrative cntractr under the direct GME payment methdlgy r a freestanding skilled nursing facility (SNF) r hme health agency (HHA) in which such payments are made n a reasnable cst basis. A nnprvider setting is a health care facility ther than a hspital, skilled nursing facility, hme health agency, r cmprehensive utpatient rehabilitatin facility fr which residents prvide services (e.g., family practice r multispecialty clinics and physician ffices). A teaching physician is physically present when that teaching physician is lcated in the same rm (r partitined r curtained area, if the rm is subdivided t accmmdate multiple patients) as the patient and/r perfrms a face-t-face service. The teaching physician determines the critical r key prtin f a service. If the requirements are met, reimbursement under Medicare Part B may be made. In all situatins, the services f a resident are payable thrugh direct graduate medical educatin (GME) payment r as reasnable cst payments made by the Medicare administrative cntractr. Evaluatin and Management Services In the case f evaluatin and management services (e.g., ffice visits and cnsultatins), the teaching physician must be present during the key prtin f the service that determines the level f service billed and must persnally dcument his r her participatin in the service in the patient s medical recrds. Fr an encunter, the selectin f the apprpriate level f evaluatin and management (E/M) service is determined accrding t the cde descriptins in the AMA s CPT cding manual and applicable dcumentatin guidelines. Fr purpses f reimbursement, the patient recrd must cntain dcumentatin that the teaching physician perfrmed the service r was physically present during key r critical prtins f services perfrmed by a resident, and participated in the management f the patient s care. Upn medical review, the cmbined entries in the patient recrd by the teaching physician and the resident cnstitute the dcumentatin fr the service, and tgether must supprt the level f E/M service billed and the medical necessity f the service. Dcumentatin by the resident f the presence and participatin f the teaching physician is nt sufficient t establish the presence and participatin f the teaching physician. If the teaching physician repeats key elements f service cmpnents btained previusly and dcumented by the resident (e.g., patient s cmplete histry and physical examinatin), the teaching physician need nt repeat dcumentatin f these cmpnents in detail. Rather, the teaching physician s dcumentatin may be brief, summary-type cmments that relate t the resident s entry and that cnfirm r revise the key elements defined fr the purpse f this sectin as: Relevant histry f present illness and prir diagnstic tests Majr finding(s) f the physical examinatin Dcumentatin Requirements fr Teaching Physicians, page 2
Assessment, clinical impressin, r diagnsis Plan f care Thus, dcumentatin f key elements may be satisfied by cmbined entries in the patient recrd recrded by the resident and the teaching physician. EXAMPLE OF MINIMALLY ACCEPTABLE DOCUMENTATION WHEN ALL REQUIRED ELEMENTS ARE OBTAINED PERSONALLY BY THE TEACHING PHYSICIAN WITHOUT A RESIDENT PRESENT The fllwing are examples f minimally acceptable dcumentatin when all required elements are btained persnally by the teaching physician withut a resident present. In this situatin, a resident may r may nt have perfrmed an independent service, and if there are n resident ntes, the teaching physician must dcument the E/M service as if in a nnteaching setting. Admitting nte: I perfrmed a histry and physical examinatin f the patient and discussed his management with the resident. I reviewed the resident s nte and agree with the dcumented findings and plan f care. Fllw-up visit: Hspital day #3. I saw and evaluated the patient. I agree with the findings and the plan f care as dcumented in the resident s nte. Fllw-up visit: Hspital day #5. I saw and examined the patient. I agree with the resident s nte except the heart murmur is luder, s I will btain an echcardigram t evaluate. EXAMPLE OF MINIMALLY ACCEPTABLE DOCUMENTATION WHEN ALL REQUIRED ELEMENTS ARE OBTAINED BY THE RESIDENT The fllwing is an example f minimally acceptable dcumentatin when all required elements are btained by the resident in the presence f, r jintly with, the teaching physician and dcumented by the resident. In this situatin, the teaching physician must dcument his presence during perfrmance f critical r key prtin(s) f the service and that he was directly invlved in the management f the patient s care. The teaching physician s nte shuld reference the resident s nte. The cmbinatin f entries must be adequate t substantiate the level f service billed and the medical necessity f the service. Initial r fllw-up visit: I was present with resident during the histry and exam. I discussed the case with the resident and agree with the findings and plan as dcumented in the resident s nte. Fllw-up visit: I saw the patient with the resident and agree with the resident s Dcumentatin Requirements fr Teaching Physicians, page 3
findings and plan. EXAMPLE OF MINIMALLY ACCEPTABLE DOCUMENTATION WHEN SELECTED REQUIRED ELEMENTS OF THE SERVIC E ARE OBTAINED BY THE RESIDENT IN THE ABSENCE OF THE TEACHING PHYSICIAN AND DOCUMENTS HIS/HER SERVICE The fllwing is an example f minimally acceptable dcumentatin when selected required elements f the service (e.g., histry and physical examinatin) are btained by the resident in the absence f the teaching physician and dcuments his/her service. The teaching physician independently perfrms the critical r key prtin(s) f the service with r withut the resident present and, as apprpriate, discusses the case with the resident. In this situatin, the teaching physician must dcument that he r she persnally saw the patient, persnally perfrmed critical r key prtins f the service, and participated in the management f the patient. The teaching physician s nte shuld reference the resident s nte. Fr payment, the cmbined entries f the teaching physician and resident must be adequate t substantiate the level f service billed and the medical necessity f the service. The fllwing are examples f acceptable dcumentatin by the teaching physician: I saw and evaluated the patient. I reviewed the resident s nte and agree, except that the picture is mre cnsistent with pericarditis than mycardial ischemia. Will begin NSAIDs. (initial visit) I saw and evaluated the patient. Discussed with resident and agree with resident s findings and plan as dcumented in the resident s nte. (initial r fllw-up visit) See resident s nte fr details. I saw and evaluated the patient and agree with the resident s finding and plans as written. (fllw-up visit) I saw and evaluated the patient. Agree with resident s nte, but lwer extremities are weaker, nw 3/5; MRI f L/S spine tday. (fllw-up visit) EXAMPLE OF UNACCEPTABLE DOCUMENTATION BY THE TEACHING PHYSICIAN The fllwing are examples f unacceptable dcumentatin by the teaching physician: Dcumentatin Requirements fr Teaching Physicians, page 4
Agree with abve Runded, reviewed, agree Discussed with resident; agree Seen and agree Patient seen and evaluated Legible cuntersignature r electrnic authenticatin f resident s nte The abve dcumentatin is nt acceptable because it is impssible t determine whether the teaching physician was present, evaluated the patient, and/r had any invlvement with the plan f care. Evaluatin and Management Dcumentatin Prvided by Medical Students Any cntributin and participatin f a medical student t the perfrmance f a billable service (ther than the review f systems and/r past family/scial histry which are nt separately billable, but are dcumented as part f an evaluatin and management service) must be perfrmed in the physical presence f a teaching physician r in the physical presence f a resident in a service meeting the requirements set frth in this sectin fr teaching physician billing. Students may dcument services in the medical recrd. Hwever, the dcumentatin f an evaluatin and management (E/M) service by a student that may be referred t by the teaching physician is limited t dcumentatin related t the review f systems and/r past family/scial histry. The teaching physician may nt refer t a student s dcumentatin f physical exam findings r medical decisin making in his r her persnal nte. If the medical student dcuments E/M services, the teaching physician must verify and redcument the histry f present illness as well as perfrm and redcument the physical exam and medical decisin-making activities f the service. A medical student is an individual wh participates in an accredited educatinal prgram (e.g., a medical schl) that is nt an apprved GME prgram. A medical student is nt an intern r a resident. Medicare des nt reimburse any service furnished by a student. Exceptin fr E/M Services Furnished in Certain Primary Care Centers Teaching physicians wh prvide evaluatin and management (E/M) services fr a GME prgram that has been granted a primary care exceptin may bill Medicare fr lwer and mid-level E/M services prvided by residents. Under this exceptin, Medicare Part B may be billed fr reasnable and necessary lw- t mid-level evaluatin and management services when furnished by a resident withut the presence f a teaching physician, if all the fllwing criteria are met: Dcumentatin Requirements fr Teaching Physicians, page 5
The services must be furnished in a center lcated in the utpatient department f a hspital r anther ambulatry care entity in which the time spent by residents in patient care activities is included in determining direct GME payments t a teaching hspital by the hspital s Medicare administrative cntractr. This requirement is nt met when the resident is assigned t a physician s ffice away frm the center r makes hme visits. Any resident furnishing the service withut the presence f a teaching physician must have cmpleted mre than 6 mnths f a GME apprved residency prgram. The center is respnsible fr furnishing this infrmatin t the Medicare administrative cntractr upn request. The teaching physician may nt supervise mre than fur residents at any given time and must direct the care frm such prximity as t cnstitute immediate availability. The teaching physician must: Nt have ther respnsibilities (including the supervisin f ther persnnel) at the time the service was prvided by the resident Have the primary medical respnsibility fr patients cared fr by the residents Ensure that the services furnished are reasnable and necessary Review the care prvided by the resident during r immediately after each visit. This must include a review f the patient s medical histry, the resident s findings n physical examinatin, the patient s diagnsis, and treatment plan (i.e., recrd f tests and therapies) Dcument the extent f his r her wn participatin in the review and directin f the services furnished t each patient The patients seen must be an identifiable grup f individuals wh cnsider the center t be their primary lcatin fr health care services. The residents must generally prvide care t the same grup f established patients thrughut the curse f their residency prgram. There is n requirement that the teaching physicians remain the same ver any perid f time. The range f services furnished by residents under this exceptin include all f the fllwing: Acute care fr undifferentiated prblems r chrnic care fr nging cnditins including chrnic mental illness Crdinatin f care furnished by ther physicians and prviders Cmprehensive care nt limited by rgan system r diagnsis Dcumentatin Requirements fr Teaching Physicians, page 6
Types f residen cy prgrams mst likely t qualify fr the primary care exceptin include family practice, general internal medicine, geriatric medicine, pediatrics, and bstetrics/gyneclgy. Certain GME prgrams in psychiatry may qualify in special situatins, such as when the prgram furnishes cmprehensive care fr chrnically mentally ill patients. These wuld include facilities in which the range f services that residents are trained t furnish, and actually d furnish, include cmprehensive medical care as well as psychiatric care (e.g., antibitics prescribed as well as psychtrpic drugs). Split/Shared Evaluatin and Management Services Billing shared/split evaluatin and management services apply t physicians and nnphysician practitiners in the same grup practice. These guidelines d nt apply t teaching physician services. Prcedures In rder t bill fr surgical, high-risk, r ther cmplex prcedures, the teaching physician must be present during all critical and key prtins f the prcedure and be immediately available t furnish services during the entire prcedure. Surgery The teaching surgen is respnsible fr the preperative, perative, and pstperative care f the patient. The teaching physician s presence is nt required during the pening and clsing f the surgical field unless these activities are cnsidered t be critical r key prtins f the prcedure. The teaching surgen may determine which pstperative visits are cnsidered key and require his r her presence. If the pstperative perid extends beynd the patient s discharge and the teaching surgen is nt prviding the patient s fllw-up care, then instructins n billing less than the glbal package apply. During nnkey prtins f the surgery, if the teaching surgen is nt physically present, he r she must be immediately available t return t the prcedure (e.g., the teaching surgen cannt be perfrming anther prcedure). If circumstances prevent a teaching physician frm being immediately available, then he r she must arrange fr anther qualified surgen t be immediately available t assist with the prcedure, if needed. Single Surgery. When the teaching surgen is present fr the entire surgery his r her presence may be demnstrated by patient recrd ntes dcumented by the surgen, resident, r perating rm nurse. Tw Overlapping Surgeries n Tw Different Patients. In rder t bill fr tw verlapping surgeries, the teaching surgen must be present during the critical r key prtins f bth peratins. Therefre, the key prtins may nt take place at the same time. When all f the key prtins f the initial prcedure have been cmpleted, the teaching surgen may begin a secnd Dcumentatin Requirements fr Teaching Physicians, page 7
Anesthesia prcedure. The teaching surgen must persnally dcument in the patient recrd that he r she was physically present during the critical r key prtin f bth prcedures. When a teaching physician is nt present during nncritical r nnkey prtins f the prcedure, and is participating in anther surgical prcedure, he r she must arrange fr anther qualified surgen t immediately assist the resident in the riginal case shuld the need arise. (In the case f three cncurrent surgical prcedures, the rle f the teaching surgen, but nt anesthesilgist, in each case is classified as a supervisry service t the hspital, rather than a physician service t an individual patient, and is nt reimbursable by Medicare.) Minr Prcedures. Fr prcedures that take nly a few minutes (5 minutes r less) t cmplete (e.g., simple suture) and that invlve relatively little decisin making nce the need fr the peratin is determined, the teaching surgen must be present fr the entire prcedure in rder t bill fr the prcedure. Endscpy Prcedures. In rder t bill fr prcedures perfrmed thrugh an The teaching physician must dcument in the patient recrd that he r she was present during all critical (r key) prtins f the prcedure. The teaching physician s physic al presence during nly the preperative r pstperative visits with the patient is nt sufficient t receive Medicare payment. If an anesthesilgist is invlved in cncurrent prcedures with mre than ne resident r with a resident and a nnphysician anesthetist (e.g., certified registered nurse anesthetist r CRNA), payment will be made as medical directin fr the anesthesilgist s services. In rder fr a teaching physician wh prvides anesthesia services in a teaching hspital t receive payment frm Medicare Part B, he r she must: Persnally participate in the mst demanding prcedures in the anesthesia plan, including inductin and emergence endscpe, the teaching physician must be present during the entire viewing. The entire viewing includes the insertin and remval f the device. Viewing f the entire prcedure thrugh a mnitr in anther rm des nt meet the teaching physician presence requirement. Prescribe the anesthesia plan Ensure that any prcedure in the anesthesia plan that he r she des nt perfrm is perfrmed by a qualified individual Mnitr the curse f anesthesia administratin at frequent intervals Remain physically present and available fr immediate diagnsis and treatment f emergencies Dcumentatin Requirements fr Teaching Physicians, page 8
The teaching physician must direct n mre than fur anesthesia prcedures cncurren tly and cannt perfrm any ther service while he r she is directing the cncurrent prcedures. If the teaching physician is invlved in furnishing mre than fur prcedures cncurrently, r is perfrming ther services while directing the cncurrent prcedures, the cncurrent anesthesia services are cnsidered t be physician services t the hspital and shuld nt be billed t Medicare Part B. A teaching physician will be reimbursed as if he r she persnally perfrmed the service, if he r she is invlved in a single anesthesia prcedure invlving a single resident. In rder t receive payment as if he r she persnally perfrmed the service, the physician cannt perfrm services invlving ther patients during the perid the anesthesia resident is furnishing services in a single case. Dcumentatin must indicate the teaching physician s presence during inductin, emergence, and any ther prtin f the prcedure payable n a time basis. The teaching physician s presence is nt required during the preperative r pstperative visits with the patient. Other Cmplex r High-Risk Prcedures In the case f cmplex r high-risk prcedures fr which natinal cverage determinatins, lcal cverage determinatins, r the CPT descriptins indicate that the prcedure requires persnal (in persn) supervisin f its perfrmance by a physician, Medicare administrative cntractrs shuld be billed nly when the teaching physician is present with the resident. The presence f the resident alne des nt meet the teaching physician presence requirement necessary fr these services. Such prcedures include interventinal radilgic and cardilgic supervisin and interpretatin, cardiac catheterizatin, cardivascular stress tests, and transesphageal echcardigraphy. Psychiatric Services The teaching physician will be cnsidered present during each visit fr which payment is sught if the teaching physician bserves the key prtin f the visit thrugh a visual device (e.g., ne-way mirrr, vide equipment). Audi-nly equipment des nt satisfy the physical presence requirement. Further, the teaching physician supervising the resident must be a physician (e.g., the teaching physician plicy des nt apply t psychlgists wh supervise psychiatry residents in apprved GME prgrams). In the case f evaluatin and management prcedures, the teaching physician must persnally dcument his r her presence and participatin in the service in the medical recrds. The teaching physician's supervisin and the resident's therapy sessin must be cnducted simultaneusly. Additinally, the teaching physician must be present fr the entire length f time f a time-based therapy. Fr example, if the teaching physician bserved 15 minutes f a 30-minute sessin thrugh a ne-way mirrr, the teaching physician can bill fr 15 minutes nly. Dcumentatin Requirements fr Teaching Physicians, page 9
Time-Based Cdes Certain CPT cdes are determined n the basis f time, and the teaching physician must be present fr the perid f time fr which the claim is made. A CPT cde that specifically describes a service fr 20 t 30 minutes is nly payable if the teaching physician is present fr 20 t 30 minutes (e.g., critical care services cdes). Payment will nt be made fr time spent by the resident in the absence f the teaching physician. Radilgy and Other Diagnstic Tests Medicare pays fr the interpretatin f diagnstic radilgy and ther diagnstic tests if the interpretatin is perfrmed by r reviewed with a teaching physician. The teaching physician need nt be present during the actual perfrmance f a radilgic r ther diagnstic test in rder t bill fr the interpretatin f the test. The physician may submit a claim fr payment f the interpretatin when he reviews the film with the resident r by perfrming an independent interpretatin, as lng as all the fllwing criteria are met: The service prvided fr the patient must be meaningful frm the standpint f affecting the curse f treatment and nt merely a rutine review f a reprt fr purpses f quality cntrl, authrizatin, validatin, r teaching. If a resident prepares and signs the interpretatin, the teaching physician must indicate that he r she has persnally reviewed the image and the resident s interpretatin and either agrees with it r edits the findings. A teaching physician s cuntersignature f the resident s interpretatin alne is nt acceptable dcumentatin. If the teaching physician s signature is the nly signature n the interpretatin, Medicare will assume that he r she persnally perfrmed the interpretatin. Miscellaneus In the case f maternity services furnished t Medicare-eligible wmen, the physician presence requirement fr bth types f delivery will be applied in the same manner as it is fr surgery. In rder t bill Medicare fr the prcedure, the teaching physician must be present fr the delivery. These prcedure cdes are smewhat different frm ther surgery cdes in that there are separate cdes fr glbal bstetrical care (prenatal, delivery, and pstpartum) and fr deliveries nly. Mnlighting The phrase services f mnlighting residents refers t services that licensed residents perfrm utside the scpe f an apprved GME prgram. Medical and surgical services furnished by interns and residents that are nt related t their training prgram, and are perfrmed utside the facility where they have their training prgram, are cvered as physicians services as lng as they meet the bulleted items belw. Dcumentatin Requirements fr Teaching Physicians, page 10
Similarly, medical and surgical services furnished by interns and residents that are nt related t their training prgram, and are perfrmed in an utpatient department r emergency rm f the hspital where they have their training prgram, are cvered as physicians services and paid n a reasnable charge basis where all f the fllwing criteria are met: The services are identifiable physicians services, the nature f which require perfrmance by the physician in persn and which cntribute t the diagnsis r treatment f the patient s cnditin. The intern r resident is fully licensed t practice medicine, stepathy, dentistry, r pdiatry by the state in which the services are perfrmed. The services can be separately identified frm thse services that are required as part f the apprved GME prgram. (Cntracts and agreements must be available fr review t ensure cmpliance.) When the abve criteria are met, the services are cnsidered t have been furnished by the individuals in their capacity as physicians and nt in their capacity as interns and residents. Assistants-at-Surgery in a Teaching Hspital An assistant-at-surgery is a physician wh actively assists the physician in charge f a case in perfrming a surgical prcedure. (A nurse practitiner, physician assistant, r clinical nurse specialist authrized t prvide such services under state law can als serve as an assistant-at-surgery.) The cnditins fr cverage f such services in teaching hspitals are mre restrictive than thse in ther settings because f the availability f residents wh are qualified t perfrm this type f service. Payment may be made fr an assistant-at-surgery in a teaching hspital if the services meet ne f the fllwing cnditins. The services: Are required as a result f exceptinal medical circumstances, e.g., emergency, life-threatening situatins such as multiple traumatic injuries, which require immediate treatment Are cmplex medical prcedures perfrmed by a team f physicians, each perfrming a discrete, unique functin integral t the perfrmance f a cmplex medical prcedure that requires the special skills f mre than ne physician Cnstitute cncurrent medical care relating t a medical cnditin that requires the presence f, and active care by, a physician f anther specialty during surgery Are medically required and are furnished by a physician wh is primarily engaged in the field f surgery, and the primary surgen has an acrss-thebard plicy f never using interns r residents in the surgical prcedures that Dcumentatin Requirements fr Teaching Physicians, page 11
the surgen perfrms (including preperative and pstperative care); generally, this exceptin is applied t cmmunity physicians wh have n invlvement in the hspital s GME prgram and in such situatins, payment may be made fr reasnable and necessary services n the same basis as in a nnteaching hspital Are nt related t a surgical prcedure fr which the CMS determines that assistants are used less than five percent f the time Payme nt u nder Medicare Part B is nt available fr assistants-at-surgery in hspitals (1) with a trai ning prgram relating t the medical specialty required fr the surgical prcedure and (2) when a resident in a training prgram relating t the specialty required fr the surgery was available t serve as an assistant-at-surgery. There may be sme instances when n qualified residents are available t assist in surgery due t a number f factrs, such as invlvement in ther activities, cmplexity f the surgery, number f residents in the prgram, r ther valid reasns. In these instances, the fllwing statement must be prvided as an attachment t the CMS - 1500 claim: I understand that sectin 1842(b)(7)(D) f the Scial Security Act generally prhibits Medicare physician fee schedule payment fr the services f assistants-at-surgery in teaching hspitals when qualified residents are available t furnish such services. I certify that the services fr which payment is claimed were medically necessary, and that n qualified resident was available t perfrm the services. I further understand that these services are subject t pstpayment review by the Medicare administrative cntractr. This certificatin statement is fr use nly when the basis fr payment is the unavailability f qualified residents in a teaching setting. There are sme situatins when the services f physicians f different specialties are necessary during surgery and when each specialist is required t play an active rle in the patient s treatment because f the existence f mre than ne medical cnditin requiring diverse, specialized medical services. Fr example, a patient s cardiac cnditin may require that a cardilgist be present t mnitr the patient s cnditin during abdminal surgery. In this type f situatin, the physician furnishing the cncurrent care is functining at a different level than th at f an assistant-at-surgery, and payment is made n a regular fee schedule basis. Dcumentatin Requirements fr Teaching Physicians, page 12
Critical Care Critical care services are time-based services. Therefre, a critical care service in a teaching hspital can nly be billed using the time that the teaching physician was in actual attendance in wrk related t the individual patient s care. When a bill is submitted fr any prcedure cde determined n the basis f time, the teaching physician must be present fr the perid f time fr which the claim is made. Because critical care is a time-based cde, the teaching physician s prgress nte must cntain dcumentatin f ttal time invlved prviding critical care services. Dcument the date and time spent with the patient n all ntes. If the time and date are nt legibly and unequivcally dcumented, the service may be subject t reductin r denial. When calculating time f a critical care service in a teaching hspital, the fllwing shuld be cnsidered: Time spent teaching (residents and/r medical students) may nt be cunted tward the critical care service time. The teaching physician must be present fr the perid f time fr which the claim is made. The teaching physician cannt bill time spent by the resident in the absence f the teaching physician. Dcum entatin supprting the services as medically necessary and reasnable must be evident in the patient s recrd. The presence and invlvement f the teaching physician shuld be reflected in the medical recrd. The dcumentatin shuld be written in such a way that it wuld be clear t anyne wh lked at the medical recrd at a later date that the invlvement f the teaching physician justified the service billed. Pints t remember when dcumenting critical care services in a teaching hspital: The teaching physician s cuntersignature f the resident s nte alne des nt dcument that a physician was present during the key prtin f the service. Althugh it is nt necessary fr the teaching physician t repeat all f the dcumentatin entered int the medical recrd by the resident, the teaching physician shuld enter additinal ntes t indicate his r her invlvement in the service. The teaching physician s dcumentatin shuld refer t the resident s nte and prvide summary cmments that establish, revise, r cnfirm the resident s findings and the apprpriate level f service required by the patient. It is nt acceptable fr the resident t dcument that he r she is runding with r being supervised by the teaching physician, r fr the teaching physician t dcument seen, examined, and agree with the resident. The nte in the patient s recrd must supprt the presence, activity, and invlvement f the teaching physician. When all required elements f the service (e.g., histry, examinatin, and medical decisin making) are btained and dcumented by the resident in the Dcumentatin Requirements fr Teaching Physicians, page 13
Mdifiers presence f r jintly with the teaching physician, the resident s nte may dcument the teaching physician s direct bservatin, perfrmance, and persnal input. The teaching physician s direct persnal dcumentatin may be limited, but at a minimum must include a cnfirmatin f each cmpnent f the resident s dcumentatin and the teaching physician s presence during the service. The cmbined entries must be adequate t substantiate the level f service required by the patient and the level f service billed. Mdifiers are 2-digit alphabetical, numerical, r alphanumeric cdes that are attached t CPT and HCPCS Level II natinal cdes (e.g., 12345-GC) t prvide additinal infrmatin abut prcedures perfrmed and services prvided. The fllwing HCPCS/CPT mdifiers shuld be reprted with the applicable prcedure and service cdes fr teaching physician services: -GC (service has been perfrmed in part by a resident under the directin f a teaching physician) -GE (service has been perfrmed by a resident withut the presence f a teaching physician under the primary care exceptin) (Mdifier -GE is reprted fr all services except ambulance services.) -82 (Assistant Surgen, when qualified resident surgen nt available) (The unavailability f a qualified resident physician surgen is a prerequisite fr reprting mdifier -82 with the prcedure cde. This mdifier is used in teaching hspitals if there is n apprved training prgram related t the medical specialty required fr the surgical prcedure, r if n qualified resident was available.) Dcumentatin Requirements fr Teaching Physicians, page 14